Mealtime Services Referral Form

Please complete this document when referring for Mealtime services.

If you would like any assistance with completing this form, please contact the Mealtime Team on 8379 6976 or via mealtime@autismsa.org.au.

CLIENT INFORMATION

Client name *

Preferred name (if different)

Pronoun

he/himshe/herthey/them

Client date of birth *

Diagnosis (please put 'none' if there is no diagnosis) *

Medical conditions/allergies (if any)

Funding stream: *

NDISFee for service (out of pocket)Other

Please detail:

NDIS number:

REFERRAL INFORMATION

Name of individual completing referral form *

Relationship to client (e.g. self, parent/caregiver, support coordinator, etc.) *

Email address

A mealtime assessment is the initial process within mealtime services at Autism SA and is carried out by a speech pathologist and occupational therapist with experience in mealtimes. The mealtime assessment allows for comprehensive multi-disciplinary assessment of the individual’s swallowing and safety within mealtimes, as well as sensory and motor impacts that may be impacting on food and drink preferences. Following completion of the assessment, the therapists will be able to provide clinical recommendations for the mealtime supports and strategies that will be most supportive for that individual.

Costing associated for a mealtime assessment it is $1,551.92. This is a total of 8 hours which includes an in-person assessment and observations, written report and recommendations, and additional individualised required services to support with targeting identified mealtime goals.

Completion of this referral form allows for allocation of the most appropriate mealtime service for the individual based on their identified needs and past mealtime assessment and/or support.

MEALTIME REFERRAL DETAILS

Has the person received any Mealtime services previously? *

NoYes

If yes, please describe:

Please upload any relevant documents below (e.g. assessments or reports) if available:

Attachment 1

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Attachment 2

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Attachment 3

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What is the reason for referral (please describe)? *

MEALTIME SERVICE BOOKING PREFERENCES

At time of completing this form my preferences are (tick all that apply):

Specify home suburb

School name

Kindy name

Day Options name/location

If other, please detail:

Time preferences (please select all that apply) *

Any time Specific time/s

Specify time/s

MEALTIME BACKGROUND INFORMATION

Other/further information

2. Are any of the below relevant for the individual? Please select all that apply. *

The individual only accepts a limited range of foods (e.g. less than 20 different foods)Difficulty transitioning from puree to solid foodsDifficulty transitioning from breast/bottle to cup drinkingMealtimes usually go for longer than 30 minutesFoods are ‘dropped off’ from an individual’s repertoire with no new foods replacing those lost (e.g. Billy ate bananas every day for a snack and then suddenly started refusing to eat bananas)Aversion or avoidance of a specific texture or nutrition group (e.g. doesn’t eat any vegetables or any soft textured foods)High family and/or individual anxiety surrounding feeding/mealtimesNone of the above are relevant

Other/further information

4. Which items does the individual currently drink from? Please select all that apply. *

Other/further information

5. Which best describes the individual’s current method of feeding? Please select all that apply. *

Fed by othersSelf feeds using hands and/or cutlery

If self feeds, please select which utensils the individual currently uses:

HandsSpoonForkKnife

Other/further information

6. Does any of the below occur for the individual during or after mealtimes? Please select all that apply. *

CoughingChokingGaggingNone of the above

How frequently does this occur?

DailyWeeklyMonthlyOther

Other/further information

What is the individuals approximate height (in cm)? *

What is the individuals approximate weight (in kg)? *

BACKGROUND INFORMATION

Please provide the following background information regarding the individual seeking to access Mealtime services.

Other/further information

How does the individual currently communicate? *

Spoken language (phrases and sentences) Spoken language but with limited ability to use language functionally to get needs metNon-speakingUses gestures/ body language to communicate Uses visuals or other AAC

Please detail which AAC system is used:

Other/further information

BEHAVIOUR SUPPORT

Does the individual have a current Positive Behavior Support Plan? *

Yes No

If yes, please upload Positive Behaviour Support plan

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Please specify:

Any other information you would like to provide?

Thank you for completeing the referral form. Please review your answers and click submit.